MEDICARE: AFFILLIATED CHILDREN'S DENTAL SPECIALISTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry		AZ

General Provider Information

NPI Number	:	1396850251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFILLIATED CHILDREN'S DENTAL SPECIALISTS

Provider Business Mailing Address
First Line	:	6320A W UNION HILLS DR
Second Line	:	SUITE # 280
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7177
Country	:	US
Telephone Number	:	623-362-1150
Fax Number	:	623-362-1353

Provider Business Practice Location Address
First Line	:	6320A W UNION HILLS DR
Second Line	:	SUITE # 280
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7177
Country	:	US
Telephone Number	:	623-362-1150
Fax Number	:	623-362-1353

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. GERI WEAVER
Credential	:
Telephone Number	:	623-362-1150

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	08/22/2020

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